A 60 year male with diabetic nephropathy
roll no: 45
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.
Following is the view of my case:
Case: A 60 year old male from tirumalagiri came to the hospital with the chief complaints of pedal oedema, shortness of breath and decresed urinary output since 3 months.
History of present illness: The patient was apparently asymptomatic 3 months ago then he developed bilateral pedal oedema which is painless and is of pitting type. He also had shortness of breath(grade:3) and decresed urinary output which is associated with burning sensation.
Past history:
•He is a known case of diabetes since 16 years and hypertension.
•He was dianosed with coronary aretery disease and percutaneous transluminal coronary angioplasty was done one and a half year ago.
Personal history: Diet: mixed; appetite: normal; bowels:normal; micturition: abnormal; sleep: adequate; no addictions since 5 years(was alcoholic before).
Family history: insignificant
General examination: The patient is conscious, coherent and cooperative. He is well oriented to time, place and person.
Built: poor ( muscle wasting over the arms and truncal obesity noticed)
Nourishment: poor
Pallor: present
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Vitals:
Temperature: afebrile
Pulse: 82 beats per minute
Respiratory rate: 20/ min
Blood pressure: 140/90 mmhg
Systemic examination:
CVS: s1 and s2 heard
RESPIRATORY SYSTEM: No dyspnoea, no wheeze, position of trachea: central, breath sounds: vehicula.
ABDOMEN:
No tenderness
No palpable mass
No free fluid
Liver: not palpable
Spleen: not palpable
Bowel sounds: heard
CNS: conscious
Speech: Normal
No neck stiffnes
Normal cranial nerves, motor and sensory system.
INVESTIGATIONS
Complete blood picture
Blood urea
Serum creatinine
Serum iron
Seum electrolytes
HBsAg
Anti HCV antibodies
ECG
Provisional diagnosis
•Diabetic nephropathy on MHD
•Known case of coronary artery disease and PTCA was done.
Treatment:
Inj. Lasix 40mg
Tab. Ecosprin
Tab. Nitroglycerin 2.5mg
Tab. Nodosis 500mg
Tab.OroFGR XT
Inj. Erythropoietin 400IU SC weekly twice
Fluid restriction <1.5 L/day
Salt restriction <4gm/day
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